Unprecedented electoral concern has triggered the sixth general inquiry into mental health policy and services.
I am an historian of New Zealand’s mental health policy who has studied the five previous major inquiries (the first held back in 1858 recommended establishing a colonial lunatic asylum providing liberal treatment). I also worked for a quarter of a century in the former Health Department/Ministry of Health – including several stints in mental health policy – and was involved with two inquiries including the Ministerial Inquiry that lead to the 1996 Mason Report.
This latest Ministerial inquiry’s brief contains familiar themes but vive les différences.
- This inquiry includes the “full spectrum” of mental health and addiction problems – from mental distress to enduring psychiatric illness – which scopes a health challenge now estimated to affect 50–80 percent of New Zealanders. Suicides are nearly twice the road toll.
- It includes both mental health and addiction needs which acknowledges the high level of co-existing conditions. The inquiry will hopefully avoid sub-setting addiction within mental health by recognising the distinctiveness and complexity of each.
- It has been set the parallel tasks of identifying and responding to people’s needs and public health and health promotion approaches. The latter task has never been so boldly stated.
- Publishing a consultation document is novel and will sharpen the customary process of submissions, hearings and meetings within the tight time-frame.
- Internal Affairs Department is servicing this inquiry; not the Ministry of Health.
As an historian I’ve found ‘applied history’ often explained incremental policy change and sometimes showed the need to break with the past. Could applied history assist this inquiry?
Healthy mental health
A positive definition of mental health should front-foot the inquiry. Mental health is a process that enables all New Zealanders to realise their abilities, deal with life’s challenges and stresses, enjoy life, work productively and contribute to their communities. Mental health is a positive sense of emotional and spiritual wellbeing that respects the importance of culture, equity, social justice, personal dignity and diversity.1
Flip that pyramid: focus on primary prevention
Earlier inquiries, reflecting official thinking, regarded mental health as a euphemism for mental disorders.
Mental health services were shorthand for specialised care, treatment and rehabilitation, particularly of high-needs individuals (now 3.6 percent of the population). Pluralistic and community-based services have superseded institutions, but thinking continues to be fed by the low priority, funding and workforce pressures, and a service supply-demand spiral inherited from the institutional era.
Administrators have fought valiantly since colonial times for adequate resources, services and standards to prevent mental deterioration and mitigate institutionalisation.
In the twentieth century, desirable outreach services – like the mental hospital paradigm, psychiatric nursing, voluntary admission, general hospital psychiatry and community care – encouraged early intervention and rehabilitation. Sporadic but important official promotion/primary prevention efforts included anti-stigma projects, the Plunket Society, eugenics policies, marriage guidance counselling, alcohol awareness and the national depression initiative.
That grossly simplified history can be depicted in public health-speak as a pyramid ascending from tertiary and secondary to primary prevention.
With its parallel tasks, the inquiry can flip that pyramid so promotion and primary prevention become the base, not the apex.
It’s like reducing road crashes through road safety rather than high-tech emergency medicine. The umbrella and life course models underlie protective measures mooted to boost psychological and emotional resilience and reduce stress-risks that lead to social alienation, isolation, withdrawal, broken relationships, multifaceted abuse, domestic violence and vulnerability to bullying and shaming. Government scientists also challenge the whole role of alcohol in society. Legal/illicit addictive substances are a logical extension.
Yesteryear’s inquiries were insular, navel-gazing affairs that occasionally glanced overseas.
It is hard nowadays to ignore the imprimatur and moral imperative of the World Health Organization (WHO). Its Mental Health Action Plan 2013-2020 presents the inquiry with a sound structural template with interlocking objectives:
- Implementing promotion and prevention strategies
- Strengthening effective leadership and governance
- Providing comprehensive, integrated and responsive mental health and social care services in community-based settings
- Strengthening information systems, evidence and research.
The Inquiry is reassuringly committed to “set a clear direction” and systemic change. The consultation document should therefore hearten everyone mystified by the jumble of official documents handed over as preliminary reading. There should be a loud bravo when the inquiry produces a thorough-going blueprint and realistic draft 5-10 year strategic action plan.
Getting our act together
This inquiry could foreshadow major change in the leadership, administration and funding of mental health and addiction because it is expected to name agencies, including the Mental Health Commission (the MHC was created as a result of the 1995-1996 Inquiry), to progress its recommendations.
Might that mean tempering the Ministry of Health’s powerful influence? Officials had their own agendas for twentieth century inquiries and advised ministers accordingly.
The mental health directorate now lies deeply embedded within the hapless, beleaguered and leaderless health ministry. Has the specialised national technocracy recommended by the 1871 inquiry, and established in 1876, now run its course?
Overseas namesakes, the Law Commission and the Parliamentary Commissioner for the Environment provide inspiration for crafting the MHC as a modern, permanent, high-powered government/parliamentary agency.
It needs superior status, strong advisory backing, generous resources, and statutory authority for proactive and over-arching leadership, consensus-building, oversight and coordination to generate momentum for sustained change across all aspects of mental health and addiction.
This sixth general mental health inquiry follows those of 1858, 1871, 1957-60, 1972-3 and 1995-6 – a generational phenomenon – if the catalytic effects in 1904 and 1925 of threatened inquiries are included.
Those inquiries certainly shaped policy and services though ‘success’ does not necessarily mean immediate and full adoption of recommendations. Inquiries may spark official alternatives or prophetically engender subsequent change.
The huge volume of often harrowing submissions to the Mason Inquiry (1995-6) proved that inquiries can be socially cathartic and no longer the preserve of ‘establishment’ professional and provider interests.
Unique features give the sixth inquiry great potential.
Its membership reflects contemporary trends of inclusiveness alongside traditional considerations like legal and medical input and geographical mix. Its lexicon includes “hope” and “system-level change.” “Listening closely,” “broad engagement” and “flexibility to respond and adapt if necessary” invite Māori, youth, Pacific people, minority, immigrant and refugee groups, LGBTIQA+ communities, prison populations, elderly people, rural/farming communities (and hopefully people affected by war or natural disaster) to join the discussion.
This inquiry can alter the long-standing conceptual underpinnings of policy and services for the full spectrum of mental problems and addictions by flipping the prevention pyramid and building upon a positive definition of mental health. WHO’s planning framework can become our own and incorporate sound Kiwi ideas. The inquiry can help enflesh the MHC.
History shows how inquiries of different shapes and sizes stimulated mental health and hopefully now addiction reform.
This inquiry offers generational hope so let’s bless it with that mock wartime fillip, ‘Keep calm and do something different.’
Dr Warwick Brunton is a historian and a retired former Senior Teaching Fellow at the University of Otago’s Department of Preventive and Social Medicine and former Associate Dean (International). This opinion article is based on a seminar he presented earlier this month at the University of Otago’s Dunedin campus.
1. Adapted from http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf
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